Marshal McLuhan in Understanding Media, 1964

“ The new media and technologies by which we amplify and extend ourselves constitute huge collective surgery carried out on the social body with complete disregard for antiseptics. If the operations are needed, the inevitability of infecting the whole system during the operation has to be considered. For in operating on society with a new technology, it is not the incised area that is most affected. The area of impact and incision is numb. It is the entire system that is changed” (p.4).

Copyright Susan M. Wieczorek & The University of Pittsburgh, 2009

Today’s Medical EnvironmentEmail, MySpace, Face Book, Twitters,

Web Pages, Patient Portals, EHRs

How are these forms of media used differently in the medical profession? What makes them unique?

Patients Are Now…• PRODUCERS of their own

Medical Charts• PARTICIPANTS in

medical decision making• RESEARCHERS of medical

information

The Impetus for Change? American Recovery & Reinvestment Act

• $787 Billion Total Stimulus Package• $19.2 Billion HITECH Act

– $2 Billion to Department of Health & Human Services (HHS) and the newly created Office of the National Coordinator for Health IT (ONC)

– $17.2 Billion to healthcare providers who can demonstrate utilization of EHRs—e-Prescribing, connectivity that allows full patient health history visibility to providers, ability to report effective use to HHS.

Email & E-Messagingas a Social Instrument of

Change In the Physician-Patient Relationship• Emails exchanged through

secured portals• Emails allowing/encouraging

patient input• Emails becoming a part of the

patient medical record.

Email: A Media Ecology Perspective“Socio-Informatics”

A hybrid of letter writing and the spoken word• Maintains the spontaneity of oral expression

• Done at anytime of day, interruption-free• Can capture the emotion while it is happening• Free-flowing ideas and thoughts representing mental state

• Provides the permanence of written word• Once the “send button” is pushed, you cannot take it back• No email is really ever “deleted”

• Transcends time and space• Message sent despite physical disability, location, or age

Email: An American Medical Informatics Association ApproachThe AMIA has defined patient-provider electronic mail as… “computer-based communication

between clinicians and patients within acontractual relationship in which the health care provider has taken on an explicit measureof responsibility for the client’s care.”

This includes medical advice, treatment, and information exchanged professionally between physicians and their patients through electronic interactions.

Institute of Medicine IOM, 2001

• Patients should receive care whenever they need it and in many forms, not just face-to-face visits.

• Health care systems must be responsive at all times and access to care should be provided over the Internet, by telephone, and by other means in addition to in-person visits.

• The key to a trusting, effective relationship involves multiple levels of communication, including but not limited to email.

Rationale Exists for EmailingBut do your patients want & need this?

Center for Studying Health System Changes “Tracking Report” August 2008 (Tu & Cohen, 2008)

• Over 122 million people in US in 2007 reported seeking information about their personal health concerns.

• Of this group 16% in 2001 and 32% in 2007 sought medical information on the Internet (a doubling of online usage by adults).

• Possible reasons for this increase: – An exponential increase in high-speech Internet residential assess

(Horrigan and Smith, 2007) – An increase in Web-based health sites for consumers (Noonan, 2007).

Tu, Ha T, and Genna R. Cohen, Striking Jump in Consumers Seeking Health Care Information, Tracking Report No. 20, Center for Studying Health System Change, Washington, D.C. (August 2008).

Tu, Ha T, and Genna R. Cohen, Striking Jump in Consumers Seeking Health Care Information, Tracking Report No. 20, Center for Studying Health System Change, Washington, D.C. (August 2008).

August 2009http://thomsonreuters.com/content/healthcare/pdf/394449/healthcare_trend_report

April 22, 2008 Alicia Chang AP Science WriterIt's no LOL: Few US doctors answer e-mails from patients

http://www.boston.com/news/health/articles/2008/04/22/its_no_lol_few_us_doctors_answer_e_mails_from_patients/?p1=Well_MostPop_Emailed7

Guidelines for the Clinical Use of Electronic Mail with Patients

The American Medical Informatics Association responded to patient need and physician concern with their own guidelines:– (1) effective interaction between

the physician and patient – (2) the need for medico- legal

prudence

AMIA General Guidelines on the Physician-Patient Relationship and Emails

• Must only be used when improving not complicating the relationship

• Must rely upon a negotiation between the patient and provider with emphasis on – turnaround time, – privacy – permissible transaction and content– discreet and categorical subject headers

• Must be formally and carefully delivered, received, and recorded. (Patients might be spontaneous but physicians must treat it like a legal document.)

AMIA Specific Guidelines on the Physician-Patient Relationship and Emails

• Use Automatic Replies to incoming messages must be sent indicating who has received the message and when it will be responded to.

• Place Email on Patient Chart. Email transactions must be archived in full and placed on the patient chart or EMR

• Have Patients Acknowledge They Received the Message. Acknowledgment of messages from the physician office should be requested from the patients to assure whether or not and at what point they received the information.

• Use a Footer to Direct Emergencies. This is necessary to help direct patients to escalate communication if an emergency arises.

• Use Blind Copies for Group Mailings. The address book and group mailings (generally with educational information)should be recorded with care and sent using a blind copy to insure privacy.

• Avoid Emotional Content to avoid misinterpretation. Omit Emoticons!

PHONE EMAILUrgent Messages Less Urgent Messages“Phone Tag” Direct Message to

ReceiverSynchronous AsynchronusNot Automatically Recorded Always RecordedNonpermanent “proof” Permanent “Proof”Constant Office Interruptions End-of-Day AnswersMore Time Consuming Less Time ConsumingAnswering Machine UncertaintyRelayed Only to Consumer

AMIA on Medico-Legal Prudence Treat Emails and Telephones Differently

AMIA on Medico-Legal Prudence Cont.Be sure email messages are encrypted

– HIPPA (Health Insurance Portability and Accountability Act) regulations state that email messages should be encrypted to prevent breaches of information or interception of data.

– Small physician practices can use software such as PGP (Pretty Good Privacy) but the patients’ computer must have the same software which can be downloaded off of the Internet.

– A secure password shared between the physician and patient enables both to have access to the medical data.

– Another possibility is a secure server messaging service (such as Healinx) which is a hybrid version of online communication. The patient goes to a third party server that is viewed as a Web page.

– Remember this is a LEGAL document and provides malpractice evidence of medical error. But no matter what the media, “The confidentiality of medical information and the privacy of email are paramount (Mandl, et al.).

AMA Guidelines for Physician-Patient Electronic communication

• Emails are not to be used to establish a patient-physician relationship

• They should only supplement other, more personal encounters such as the office visit.

• AMA recommends that emails be – restricted to professional interactions– placed in the patient’s EMR/Chart

• http://www.ama-assn.org/ama/pub/category/print/2386.html

Reimbursement Possibilities

• American College of Physician Executives– Stated that over half the physicians surveyed

stated that they would be willing to email medical advice to patients if they were reimbursed.

• Aetna and Cigna ($25 per consultation)

The Future• From….Apple iPhones 3G and Push Emails

– Doylestown Hospital, Philadelphia– 360 independent physicians in contact 24/7

• To….Hawaii Medical Service Association– Blue Cross Blue Shield Licensee– Began January 15, 2009– An Internet version of the house call– American Well (Internet Service)– 700,000 members use the service for a $10 fee– Nonmembers are charged $45– Each additional minute is $10

“Once a new technology comes into a social milieu it cannot cease to permeate that milieu until every institution is saturated.” (McLuhan, 1964)

SusanW@Pitt.edu

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